CurrentHighmark Blueshield NenyPolicy N/A

Outpatient infliximab (medical injectable) authorization request form

This document is an outpatient medical benefit authorization request form for infliximab products used across labeled indications; it governs providers requesting prior authorization for infusion or specialty-dispensed infliximab for Highmark BlueShield NENY members.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient infliximab (medical injectable) authorization request form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit completed prior authorization form with diagnosis, prior therapies tried/failed, member weight, last infusion date (if continuation), and supporting clinical documentation attached.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4preferred product options listed

8diagnosis options listed on form

1fax number for submission

Yes/Nosite-of-care hospital-affiliation checkbox

Coverage Criteria and Medical Necessity

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Initial and continuation authorization supporting criteria

Coverage consideration requires documentation of ALL of the following for most members (Medicare exception noted):

Member identification and provider data: Completed form with member name, DOB/UMI, requesting physician name and NPI, contact information, and site-of-care details (place of administration and dispensing method).

Support: form header and site-of-care/dispensing fields

Diagnosis and clinical severity: Documented ICD-10 diagnosis code and selected indication from the form (e.g., RA, CD, UC, AS, PsA, JIA, non-infectious uveitis) and statement whether disease is moderate to severe.

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Prior therapies: List all previous therapies tried and failed; for requests for a non-preferred infliximab product provide documentation of an adequate therapeutic trial and failure, intolerance, or contraindication to BOTH preferred products (Remicade J1745, Renflexis Q5104, Avsola Q5121).

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Medicare exception: Medicare members currently established on a non-preferred infliximab product are not required to try preferred options.

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Combination therapy rationale: Indicate whether infliximab is being used in combination with methotrexate; if NO, provide an explanation.

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Request type specific information: For continuation requests, provide date of last infusion and documentation that the member has demonstrated disease stability or a beneficial response to therapy.

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Attachments: Attach all pertinent clinical information and confirm attachments on the form.

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The form does not list any explicit exclusions for infliximab requests. It identifies preferred and non-preferred product options and describes exceptions for Medicare members but does not provide an exclusions section that prohibits specific indications or member groups from requesting outpatient infliximab.

A request may be determined not medically necessary when the required clinical documentation is missing or incomplete. Required information includes a documented ICD-10 diagnosis, the list of previous therapies tried and failed, member weight, and for continuation requests the date of last infusion and evidence of benefit or disease stability; failure to attach pertinent clinical information may support a denial. Additionally, when requesting a non-preferred infliximab product for a non‑Medicare member, the form requires documentation of an adequate therapeutic trial with documented failure, intolerance, or contraindication to BOTH preferred products (Remicade J1745, Renflexis Q5104, Avsola Q5121); lack of that documentation may render the request not medically necessary.

Provider Requirements, Prior Authorization, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for outpatient infliximab products. Complete and submit the Outpatient Medical Injectable Infliximab Authorization Request Form (Medical Benefit only).

Fax completed form to 833-619-5745
Medicare members established on non-preferred therapy are exempt from step therapy

Step Therapy

Preferred Product Step Therapy

Preferred infliximab products must be tried and documented as failed, intolerant, or contraindicated before a non-preferred product will be approved for commercial members.

Preferred products: Remicade (J1745), Renflexis (Q5104), Avsola (Q5121)
Non-preferred example: Inflectra (Q5103) — approval requires documented failure/intolerance/contraindication to BOTH preferred products
Medicare members currently established on non-preferred therapy are not required to try preferred options

Documentation Required

Required Form Fields and Attachments

The request may be denied if required form fields or attachments are incomplete or missing. Ensure all relevant identifiers, diagnosis, and clinical documentation are provided.

Required member identifiers: Member name, DOB, Member UMI, address, and payer (Medicare or Commercial)
Requesting physician details: Physician name, NPI, address, office contact, phone, and fax
Diagnosis information: ICD-10 diagnosis code and diagnosis description
Clinical data: Member weight, indication selection, whether infliximab is used with methotrexate (and explanation if NO), disease severity, date of last infusion, and response/stability status
Attach all pertinent clinical information (labs, notes, prior therapy records). Indicate Attached: YES/NO

Note

Site-of-Care and Drug Dispensing Information

Provide site-of-care details and select the drug dispensing method on the form. Incomplete site or dispensing information may delay or result in denial of the request.

Site of care options: Home infusion, Office Professional, Ambulatory Infusion Suite Professional, Outpatient Hospital
Indicate whether the site is hospital-affiliated or will be billed as a facility claim: Yes / No
Drug dispensing: Supplied by a Specialty Pharmacy (include pharmacy name and NPI) OR Buy & Bill (for Office Professional or Outpatient Hospital)

Denial Risk

Denial Risk: Failure to Document Preferred Product Trials

Requests may be denied if the provider fails to document prior trials of preferred infliximab products or does not provide adequate clinical rationale for using a non-preferred agent.

Document trials of preferred products and specify reason for failure/intolerance/contraindication to each preferred agent
A non-preferred product will be considered only after an adequate therapeutic trial of BOTH preferred products has failed, or when both are intolerable or contraindicated

Denial Risk

Denial Risk: Missing Clinical Information

Requests lacking a diagnosis, prior therapies tried, and documentation of response or intolerance may be denied. Submit complete clinical history and attachments to avoid denial.

Ensure diagnosis code and description are present
List all previous therapies tried and outcomes (failed, intolerant, or contraindicated)
Attach supporting clinical documentation (progress notes, lab results, infusion records) demonstrating disease severity and treatment response

OpenPayer

Outpatient infliximab (medical injectable) authorization request form

Coverage Criteria and Medical Necessity

Product Codes and Clinical Fields

Provider Requirements, Prior Authorization, and Denial Risks

Form Fields and Therapy Context

Background Information

J1745	Remicade
Q5104	Renflexis
Q5121	Avsola
Q5103	Inflectra